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Psychology of Injured Athlete
Dr. Duane “Spike” MillslagleProfessorMotor behavioral SpecialistUniversity of Minnesota Duluth
Part I
•Introduction & Personality Correlates
Introduction
•Athletic injuries are increasing despite safer equipment and rule changes.▫In secondary and collegiate levels in U.S.
Athletic Injuries are estimated at: 750,000 per year (Bergandi, 1985) 850,000 or more (Noble, et al, 1982)
•The causes of athletic injury range widely.▫Accident, Aggressive behavior, overtraining,
high-risk sports, et al.
Introduction
•Psychodynamic dimension of sport injuries may explain why:▫Some athlete become injured▫Some athlete do not recover from an injury▫Some athlete rehab is shorter than others.▫Some athlete adhere to their rehab
schedule and other do not.
Personality Correlates related to Athletic Injuries• Personality Determinates During Injury Rehabilitation
(Wittig & Schurr, 1994)
▫ Neurotic behavior▫ Pessimistic Explanatory Style▫ Overestimator▫ Dispositional optimism▫ Hardiness▫ Stress▫ Depression▫ Attitude
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Neurotic Behavior• Selective attention to the negative emotions to
injury▫Anger (“I was not a nice person during rehab)▫Emotionally venting on the PT▫Self-blame for the injury▫Withdrawal (e.g., not coming to rehab)
• Tendency to rely on the following ineffective coping strategies▫Denial that they need rehab, ▫Withdrawal and disengagement from the program,
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Pessimistic explanatory style
•Pessimistic explanatory style▫”I’m never going to _____ the rest of my
life”▫ Considered to a stable disposition across
other situations not just the injury or recovery.
•Health effects▫Immune system function▫Poorer health
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Overestimators•Non athletes and athletes in general
perceive injury as more serious than it really is when compared to the PT perception (Crossman & Jamieson, 1985)
•There are a group of non-athletes and athletes that are overestimators:▫Perceive greater pain, ▫and shows slow recover.
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Dispositional Optimism
•Investigations are consistent▫Cardiovascular and,▫Immunological function is associated with
optimism (Peterson et.al, 1991;Scheiver & Carver, 1987)
•Link between optimism and faster recovery
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Hardiness
•“Constellation of personality characteristics that function as a resistance resource in the encountering of stressful life events”-Kobass, et. al. 1982. P. 169
•Components are▫Commitment- strong beliefs in one own
value▫Challenge- views difficulties can be over come▫Control- strong sense of personal power
Stress and Depression levels
•High stress and being depressed are non compliance determinates of rehabilitation and exercise.
•You need to be certified to counsel these areas but we can screen the client’s level of stress or depression.
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In summary•Non athletes and athletes who display
neurotic behavior, over estimators tendencies, report being stressed out, show signs of being depressed, and/or display pessimistic attitude will adopt maladaptive behaviors (e.g., withdrawal, anger) which results in longer rehab or incomplete recovery
▫Grove, Stewart & Gordon (1990) with clients with ACL damage
▫Grove & Bahnsen (1997) with 72 injured athletes
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What can one do?
•Conduct an informal one-to-one visit & pay attention to the Athlete’s comments:▫Fear, sadness, embarrassment, guilt, anger,
and feelings of being over whelmed by the demands of rehab—signs of neuroticism & over estimator
•Ask the client “Why do you feel rehabilitation will help?” statement….▫Insight into athlete’s explanatory style
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Then what?▫ Keep them involved in some form of rehabilitation by
providing them meaningful incentives (e.g rewards).▫ Provide them regular steady feedback on their progress
whether it verbal or recording their progress.▫ Maintain their fitness level by redirecting them to another
physical area such as swimming, cycling, walking, etc.▫ They need social validation by significant others, spouses,
and relatives.▫ Attempt to remove perceived barriers such as providing a
flexible scheduling of appointments, providing access to rehab center, and transportation resources.
▫ Provide strategies or techniques to cope with pain or rehab (e.g. goal setting, attentional focus)
The End
Psychological Skills Training & RehabilitationPART II
Psychological Skills & Rehabilitation
•Brewer (2000) investigated the effects of psychological skills on rehabilitation adherence and outcome▫95 patients at sport medicine clinic with
ACL knee surgery▫Motivation, reducing stress, and enhancing
adherence produced better outcomes in the patients.
Psychological Skills & Rehabilitation
•Scherzer (2001) involving 54 patients undergoing ACL reconstructions were studied.▫Found that goal setting was significant
predictor of rehabilitation aherence▫Positive self-talk was associated with
completion of home exercises
Psychological Skills & Rehabilitation
•Johnson (200) study of 54 national and international injured athlete who were involved in long-term rehab after athletic injury.▫One group of injured athletes were involved in
3 mental training sessions of stress management, goals setting, and imagery.
▫Results found that short-term psychological skill training enhanced mood in the injured athletes
▫This group showed high self-rated perceptions of physical readiness to return to sport
In Summary
•Psychological Interventions that target▫Motivation▫Reduce psychological stress▫Goal setting▫Imagery,▫Self-talk, and▫Techniques that enhance adherence should
be used to better rehab outcome.
Stress Management
Stress Management SIT (Stress Inoculation Training)Cognitive-affective stress management Training
(SMT)Systematic DesensitizationSelf-talk strategiesStay physically active
Coping Techniques
An individual is exposed to and learns to cope with stress (via productive thoughts, mental images, and self- statements) in increasing amounts, thereby enhancing his or her immunity to stress.
Stress–inoculation training (SIT)
Stress Inoculation Training
Kerr & Gross found that SIT was effective in helping athletes cope with the stress of injury.
SIT teaches skills for coping with
psychological stressors.
Three Phases of SITConceptualized stage.
-Awareness of the effects of positive and negative self-talk
Rehearsal stage-Injured athlete learns to use healing imagery and positive self-talk
Application stage-athlete practice imagery and positive self-talk in low stressful situations-gradually progress to applying positive imagery and self-talk in more stressful situations
Cognitive Affective Stress Management Training (SMT)Most comprehensive stress management
approachSMT involves
- coping response using relaxation and cognitive components to control emotional arousal.- Injured athlete are an ideal population for SMT because they face stressful rehab and return to competition problems
SMT Phases
Pretreatment AssessmentTreatment rationaleSkill acquisitionSkill rehearsal
Pretreatment Assessment PhaseConduct personal interviews to assess the
injured athletes stress:- circumstances that produces stress- Their responses to stress- How their responses affect their behaviors
Treatment Rationale Phase
Focus is on helping the injured athlete:- Educate the athlete- Help them understand their stress response- Increase self-control
The emphasis is education, not psychotherapy
Skill Acquisition PhaseDevelop coping responses by:
- Relaxation training- Cognitive intervention skill training
Cognitive intervention skill training involves:- irrational to rational self-talk- reconstruct self-statements
“I won’t be worth anything” to “I’ll be good person no matter wether I win or lose”
Skill Rehearsal
Use the coping skills of relaxation and cognitive strategies:- During early training when one just returns to activity or sport use coping skills and cognitive strategies - Gradually increase the intensity of training (stress) and have the athlete use the coping skills.
Self-Talk
Where the mind goes so does the body!
Usually mind will fail you before the body!
The key to controlling the mind is self-talk!
Common Uses of Self-Talk
• Skill acquisition•Changing bad habits•Attention control (being in present)•Creating mood•Controlling one’s effort•Building self-confidence•Injury rehabilitation•Exercise Adherence
Self-talk and Injured Athlete
More self-critical thoughts than positive talk.
Negative thoughts were associate with ability to return to competition.
Injured athlete exhibited little change in their thought patter unless taught
How does positive self-talk help?•It helps the injured athlete to:
▫Stay appropriately focused on their rehab▫Foster positive expectations
What type of self-talk do you use?•Positive or Negative?
▫What do you say to yourself after the injury?
▫What thoughts appear during rehab?▫When do you use self-talk?▫Common themes that appear across the
rehab?▫What cue words do you use in self-talk?
Cognitive Techniques to Control the Mind•Thought stoppage•Changing negative thought to positive
thought!•Rational thought•Designing coping and mastery self-talk
tapes•Parking
Thought Stoppage
•Negative thought come into your mind….you stop it!
•Cue or trigger word that snaps you back to positive thought▫Snapping your finger▫Hitting your hand against your thigh
Changing Negative Thought to Positive ThoughtList all the types of self-talk that you
associate with the injuryTry to substitute a positive statement for
each negative statement.Create a chart with negative thoughts in
one column and your corresponding positive self-talk in another.
Negative Self-talk to positive Self-Talk
•You idiot-how could you get injured
•I’ll never recover from this injury
•I can’t do my rehab
•Everyone get injured-just concentrate on rehab
•Healing takes time.
•Just take one day at a time and make rehab fun
Rational Thought
•Irrational thought▫I am never every going to play again.▫I am not good injured, so what is the point!▫My season is lost, so what is the point.
•Rational thought▫The trainers and physical therapist told me
that I will recover from the injury quicker if I complete the rehab exercises correctly.
Master Self-Talk Tape
With pleasant or motivational musicWith positive cue words or statementsPositive Self-affirmation statements
- You can do it!- Just do it!- Feel it! See it! Perform it!- No pain, no gain!
ParkingWhile performing and negative though
intrudes your thought. “Park it” and then deal with it after the performance is over!
One of the distinguishing factors between a good athlete and poor athlete is:- good athlete are able to deal with set backs while poor athlete cannot. “Park it”
Healing Imagery
“Imagination is more important than knowledge” – Albert Einstein
Mind-Body Integration- Facilitates the healing process
- Increased immune response between imagery and lymphocyte function.
- Immune system is triggered by imagery
History
Ancient time the removal of pathogenic image was necessary for a cure.- images led to pathology (Aristole)- images were movement of the soul
Middle Ages- Vital spirits traveled between the heart and brain- Imagination became a predominate role in pathology
History
Pre modern times- All illness were regarded as psychosomatic- Blindness was a loss of sensation of reality- Imagery was a key interventions
History
Imagery ended in 17th century as predominate intervention due to dualism (mind and body are separate)- bleed became popular
In the 18th & 19th century, imagery was defined as the content of the mind and end product of sensation.- Illness that had no explanation were imaginal
History
20th Century- Link between imagination and pathology- Edmund Jacobson work in relaxation- Cancer research
Mental Imagery
Positive imagery are useful in enhancing one’s believe and mobilizing one’s own healing powers.
Simonton, et al (1978) cancer patient study found relaxation and imagery showed 41% improved, 22.2% had total remission, and 19.1 tumor regression.
Hull replicated Simonton study and found similar results.
Ievleva & Orlick Study
35 injured athletes used 3 types of imagery- Healing imagery (see and feel the body
part healing)- Imagery during physiotherapy (imaged
the treatment promoted recovery)- Total recovery imagery (imaged total
recovery)
ResultsInjured athletes with knee and ankle
injuries participated in the study.
Mental imagery was a focus of the study
19% of these athletes had exceptionally fast recoveries that used any form of imagery
Recovery time was significantly shorter for those athletes that used imagery than athletes that did not.
Healing ImageryDefined as visualizing and feeling the
healing taking place to the injured area.
“Imagine the clot formation around the fracture, the change of the clot into fibrous tissue lattice, calcium crystallization on the latticework, and restructuring of new bone around the fracture.”
Injury Use During Rehab From Injury
Evans, Hare, & Mullen (2006) Journal of Imagery Research Sport & Physical Activity.
Purpose
•Greater understanding of injured athletes across the phases of their rehab
During the first week
•Athletes experience intense feels of depression & frustration
•Imagery was used for healing and pain management purposes
•Rehearse and maintain skills enhanced self-confidence
Mid-Phase
•Athlete wanted to see progress in their rehab
•Maintain their performance levels
•Increases their use of healing and pain imagery
•Used imagery to motivate them to complete rehabilation
In Final Phase
•Primarily concerned with returning to sport
•Used imagery to foster their self-confidence
•Overcome fear on re-injury•Cope with the return to sport
I’ve done so much imagery between getting injured and now…I’m still a lot closer to the real performance than I would be if I had not done nothing. I think that maybe the reason behind the successful performance in the competition last week, in that I mean even though I’d been 2 months without any training at all, you known it just kinda came naturally to me, it was amazing, technically, I hadn’t lost a thing. (Evan, Hare, & Mullen, 2006)
Healing Imagery
First relax then image.Imagine the mending of the injuryImagine the body being repaired by the
treatmentInternal imageryPractice imagery dailyInvolves all the senses not just vision
Final Note on Imagery
Winners see what they want to happen, losers see what they fear— Linda Bunker
Return to SportPart III
•Return to sport is both the ultimate goal of rehab
•A source of doubt and worry about the uncertainty of injured athlete’s abilities to return to a level at or above where they performed prior to the injury
Approaches• It can be threat
▫ Low confidence▫ Decreased adherence to rehab▫ Increase in pain▫ Display avoidance behaviors▫ Increases anxiety▫ Reduced motivation
• It can be challenge▫ Positive attitude▫ High motivation▫ Excitement▫ Increased effort in rehab▫ Greater desire to return to sport▫ Overadherence to rehab▫ Greater risk of reinjury due to permature return
Stages of Return to SportInitial Return to Sport
Recovery confirmation
Return of Physical & Technical Abilities
High Intensity Training
Return to Competition
Initial Stage• Considered to be the most difficult• Athlete quickly determines the effectiveness of
the rehabilitation• Entire stage should include a series of tests of
the healed area• Athlete’s expectation are:
▫ They will perform at the same level as prior to the injury▫ Pain will not be present
• Discussion with the athlete are needed to examine their expectations.
• A concern of AT is that athlete become “overzealous” in their approach to train and compete.
Recovery Confirmation• More psychological than physical• Involves the athletes’ obtaining evidence from
initial stage that the injury is healed and ready to face the demands of the sport participation
• This is considered the make or break period▫ Athlete’s initial play will confirm their attitudes and
approaches Success will lead to higher levels of self-confidence and
motivation Injury does not swell, no pain, full range of motion, Self-confident and motivated
Not being successful will lead to doubt if they will be able to return. Swelling occurs, unexpected pain, little range of motion, decrease
strength Highly anxious and depressed
Return of Physical & Technical Skills
High intensity training marks the absolute conclusion of athlete’s identification that they are fully healed.
Re-establishment of their regimen of physical conditioning and technical training
Major psychological concern is their level of perceived preparedness:- Provide a safe,- progressive conditioning program developed by the AT or physical trainer
Return to Competition
•First post-injury competition is key concern:▫Athlete is usually more anxious than at any
other time▫Initial uncertainty▫Athlete may have a distorted perception of the
probability of the injury occurring again.•Need to discuss with the athlete’s their
attitude and feeling about the upcoming competition▫Athlete should not be thinking negatively▫Athlete needs to redirect their focus to their
skills, game strategy, and goals.
Fear of Injury: A Major Concern
•Perception that recovery is incomplete,•returning to sport to soon, • impatient in returning to sport, • lack of acceptance of the risk of the sport,• low confidence, •highly anxious, •and preoccupied with being re-injured
Prevention of Fear of Reinjury
Continue involving in the sport during rehab
View rehab as a form of athlete performance
Becoming involved with a coping modelPerformance imageryGive the athlete time to progressively
regain their physical, psychological, and technical skills.
Treatment of Fear of Injury
•Need to take a proactive approach to alleviate the fear▫Athlete needs to face a similar situation as
when the injury occurred.▫Rational self-talk helps the athlete refocus▫Simulation practice▫Relaxation techniques ▫Athlete establish pre-competition and
competition routines
Self-Determination Model & Return to Sport•Ryan & Deci (2000) focused on:
▫Competence,▫Autonomy, and▫Relatedness in explaining the athlete’s
return to sport.•From the self-determination perspective,
the success of an athlete’s return to sport from injury is related to meeting these psychological needs
Competency Issues
Athlete’s fear and concerns of returning to sport
Loss of enjoyment because they could not participate in the sport
Injury blocked their short & long term goals
Letting down others, teammates, and coaches
Issues
• Competence
• Relatedness
• Autonomy
Competence Issues
- Fear related to returning to sport
- Injury blocked their sport goals
- Overcoming their fear of reinjuryRelatedness Issues
- Feels of separation from team
- Support in re-entry into sport
- Having role models Autonomy Issues
- Sense of personal control
- Pressure to return to sport
Implications
• Competence
• Relatedness
• Autonomy
Regarding the assistance and management of athletes returning to sport following an injury:
- Rehab environments should:
1) Set goals
2) Giving the athlete choices when to return to sport
3) Provide role models
4) Rehab should be safe
The END